Provider Demographics
NPI:1467187633
Name:RUGG, RANDALL DAVID (PMHNP)
Entity Type:Individual
Prefix:MR
First Name:RANDALL
Middle Name:DAVID
Last Name:RUGG
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4207 SE WOODSTOCK BLVD # 429
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-6267
Mailing Address - Country:US
Mailing Address - Phone:503-682-5000
Mailing Address - Fax:
Practice Address - Street 1:7105 SW VARNS ST STE 270
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-8173
Practice Address - Country:US
Practice Address - Phone:503-389-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202210677NP-PP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health